Borderline Personality Disorder: Diagnosis, Causes, & Treatment

What is borderline personality disorder?

Borderline personality disorder (BPD) is a complex mental health condition characterized by pervasive instability in moods, behavior, self-image, and interpersonal relationships. As a serious mental disorder, BPD can significantly impair a person's ability to function in daily life. People with BPD often experience intense and volatile emotions, have a fragile sense of self, and struggle with impulsivity. They may engage in self-destructive behaviors and have a deep fear of abandonment that leads to unstable relationships. While the exact causes are not fully understood, BPD likely results from a combination of genetic, neurobiological, and environmental factors. With proper treatment, often involving specialized forms of psychotherapy, many people with BPD are able to reduce their symptoms and improve their quality of life over time.

It is a personality disorder, or a persistent abnormal behavior pattern manifesting during childhood or adolescence, involving unstable mood and relationships, unstable self-image, and recurrent self-harm or suicidal behavior. Factors contributing to the development of borderline personality disorder include genetic factors, environmental factors, changes in brain circuitry, and hormonal imbalances.

The diagnosis is made by a clinical assessment of meeting at least five of the nine diagnostic criteria.

Treatment focuses on psychotherapy and family therapy, with psychiatric medications as a supplemental treatment modality, and hospitalization for self-harm or suicidal intent.

You should visit your physician to discuss symptoms and treatment options. You most likely will be sent to a specialist for counseling and prescription medication.

Borderline personality disorder symptoms

According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), borderline personality disorder is diagnosed based on five or more of the following nine criteria. Symptoms usually begin in adolescence and become more pronounced in young adulthood.

Diagnostic Criteria

The nine diagnostic criteria are:

• Frantic efforts to avoid real or imagined abandonment: People with borderline personality disorder tend to feel that life is not worth living unless they feel connected to someone who really "cares," and often demonstrate frantic efforts to avoid real or imagined abandonment.
• A pattern of unstable and intense interpersonal relationships that are characterized by alternating between the extremes of idealization and devaluation: When people with borderline personality disorder perceive a rejection in the relationship, they can dramatically shift their opinion of the other person, resulting in a phenomenon called "splitting" in which people are viewed as either "all good" or "all bad."
• Markedly and persistently unstable self-image or sense of self:People with borderline personality disorder often demonstrate body image problems.
• Impulsivity in at least two areas that are potentially self-damaging: These include excess spending, unsafe sexual practices, substance abuse, reckless driving, or binge eating.
• Recurrent suicidal behavior, gestures, or threats or self-mutilating behavior: Borderline personality disorder is associated with a high risk of self-injury or suicide attempts. Self-injury or suicide attempts among people with borderline personality disorder result in an average of one emergency room visit every two years, with a suicide rate of eight to 10 percent.
• Affective instability due to a marked reactivity of mood: People with borderline personality disorder can demonstrate markedly unstable or reactive moods, such as episodes of intense sadness, irritability, and/or anxiety that last for only a few hours.
• A chronic feeling of emptiness
• Inappropriate, intense anger or difficulty in controlling anger:People with borderline personality disorder may experience episodes of intense anger that result in behaviors such as frequent displays of anger or recurrent physical fights.
• Transient, stress-related paranoid ideation or severe dissociative symptoms: People with borderline personality disorder may these symptoms, in which they may be unable to recall their own identity.

Borderline personality disorder causes

Borderline personality disorder usually does not have one distinct cause, and rather is the result of a combination of genetics, environmental factors, and changes in the brain and hormone levels.

Genetics

Some cases of borderline personality disorder are believed to be related to genetic factors. Borderline personality disorder has been estimated to be about 70 percent heritable, and borderline personality disorder has been shown to run in families.

Environmental factors

Certain environmental factors can lead to acquiring borderline personality disorder, including:

• Childhood neglect
• Childhood trauma, which is the most significant environmental risk factor for borderline personality disorder
• Abnormal attachment to a primary caregiver
• Family marital problems or psychiatric problems

Changes in brain circuitry

People with borderline personality disorder have demonstrated certain changes in brain circuitry. Specifically, people with borderline personality disorder tend to have:

• Increased activity in the amygdala, the part of the brain responsible for fear sensations
• Impaired inhibition of the prefrontal cortex, the part of the brain responsible for moderating social interaction and emotional response

Hormonal imbalances

Hormonal imbalances are thought to contribute to the development of borderline personality disorder. People with borderline personality disorder tend to have:

• Higher levels of stress hormones such as cortisol
• Decreased levels of oxytocin, a hormone that normally dampens the stress response

Treatment options and prevention

Borderline personality disorder is a chronic condition, which means it cannot be cured. Treatment focuses on managing the symptoms of borderline personality disorder and preventing high-risk circumstances such as self-harm or suicide. Specific components of treatment include psychotherapy, medications, and support from family and a medical team.

First-line treatment

The primary treatment for borderline personality disorder is psychotherapy, or "talk therapy," which usually involves seeing a therapist for two to three hours per week for one or more years. Medications are often used in conjunction with psychotherapy.

• Psychotherapy: Multiple types of psychotherapy have been shown to be effective for borderline personality disorder, including dialectical behavior therapy, mentalization-based therapy, transference-focused therapy, and general psychiatric management. The best-studied method is dialectical behavior therapy, which teaches the individual to regulate feelings and behaviors, with the therapist acting as a coach.
• Psychiatric medications: Psychiatric medications, including antidepressants such as fluoxetine (Prozac) or sertraline (Zoloft), are often prescribed to people with borderline personality disorder. However, most studies show that they do not have a significant benefit. Some medications have been shown to help with specific symptoms of borderline personality disorder, such as olanzapine (Zyprexa) for psychotic symptoms and lamotrigine (Lamictal) for mood instability.

Further support

Beyond talk therapy and medication, it is crucial for individuals with borderline personality disorder to have a steady support system as well as access to a hospital if they become suicidal or they have plans of self-harm.

• Family support: Family support is an important part of the treatment for borderline personality disorder. Family members can be taught to accommodate the issues that people with borderline personality disorder face and reach out for help if needed.
• Hospitalization: People with borderline personality disorder who demonstrate an intent for self-harm or suicide may need to be temporarily hospitalized for their safety, sometimes against their will. These cases usually involve contact with the individual's family members and the development of a plan for management and prevention after leaving the hospital.

Prevention

Currently, there are no proven methods of preventing the development of borderline personality disorder, but some programs have been developed that provide early intervention to individuals with risk factors for borderline personality disorder.

When to seek further consultation

If you or a family member have symptoms of borderline personality disorder, you should go see your physician. Your physician can perform an evaluation to determine if you or your family member has a diagnosis of borderline personality disorder and help develop a plan for management.